By Melinda Young, Author


Elder abuse harms more than one million Americans, and case managers should know how to identify it by assessing patients for signs of harm.

• Studies increasingly are showing how some elderly residents with dementia are victims of resident-to-resident violence in long-term care homes, particularly if lack of adequate staffing leads to neglect.

• New research found a link between abuse and falls reports among elderly patients.

• The first step to assessing patients for elder abuse is to ask them if they feel safe.

Elder abuse affects an estimated 1 million to 2 million Americans and is largely perpetrated by caregivers or loved ones. It also can be caused by failures in healthcare facilities. Researchers are beginning to understand more thoroughly the sorts of dangers abuse and violence pose for elderly patients and residents of nursing homes and assisted living centers.1

Case managers might be well-trained to identify signs of physical abuse in elderly patients. But there still are some signs and possibilities they might miss.

For instance, patients in nursing homes or assisted living centers might be attacked by another patient and the injury may be passed off as a fall — or not reported at all.

The phenomenon of violence between residents in long-term care facilities encompasses a broad spectrum, says Eilon Caspi, PhD, gerontologist and dementia behavior specialist and research associate in the school of nursing at the University of Minnesota.

“The incidences between residents could be mild, or at the other end of the spectrum: severe with injuries, falls, and death,” Caspi says. “It’s prevalent in long-term care homes, and we have a rapidly growing number of studies on this phenomenon.”

New research has found a link between abuse and falls reports among elderly patients.1

Researchers have looked at elder abuse and investigators have studied elderly patient falls, but research that looks at both is new, says Carlos A. Reyes-Ortiz, MD, PhD, associate professor and geriatrician, and researcher at the Texas Elder Abuse Mistreatment (TEAM) Institute, Consortium on Aging at the University of Texas Health Science Center in Houston.

Patients with a history of emotional, physical, or sexual abuse were associated with falling as older adults, research shows.2

“It’s a strong association,” Reyes-Ortiz says. “We think previous abuse may facilitate falling.”

Previous abuse could lead to post-traumatic stress disorder (PTSD), which all of the research participants in Bogotá, Colombia, experienced, he says.

In the case of physical abuse, it’s a good possibility they are pushed, he adds.

Case managers also might have patients suffering from chronic pain, and often these patients have a history of abuse. “So we need to be aware that history of abuse could be related to many other problems that we see in the adult population,” Reyes-Ortiz says.

Research has shown that elder abuse is associated with increased dementia, delusions, depression, and disability. Other, less visible abuse problems include neglect, exploitation, emotional harm, and caregivers exhibiting controlling behavior around the elderly patient.1

“In any healthcare setting, healthcare workers must be cognizant of the demeanor of the patient, whether they appear quiet and appear fearful or are open and honest and talking away,” says Jeanette M. Daly, RN, PhD, research scientist at the University of Iowa in Iowa City.

If the patient seems fearful, the case manager should speak with the patient alone and ask if he or she feels safe at home, she suggests.

“Then, depending on that answer, you do other assessments if you suspect abuse,” Daly says. “Observe physical signs of abuse, such as a bruise in an unusual spot.”

A case manager could ask a direct question of “Have you ever been hit?” Or, ask about a more subtle form of elder abuse, involving medications, Daly suggests.

“Do they get the meds they are supposed to get?” she says.

Some caregivers of the elderly might divert their medications, using or selling pills, and not giving them to the patient.

Often, the patients who are being abused are not aware that there is a name for what is happening to them, so screening is important because it’s unlikely they’ll report the abuse.

Daly’s evidence-based practice guidelines for preventing elder abuse include a chart with assessment suggestions, including the following:

• asking the patient if he or she feels safe;

• if abuse is suspected, ask the patient if he or she is at risk;

• screen patient for risk of abuse;

• conduct a patient history;

• conduct an assessment;

• interview significant others who are present with the patient;

• when indicated, use an abuse assessment tool.1

The incidence of violence and abuse in long-term care facilities sometimes is overlooked when it involves resident-on-resident aggression associated with dementia and staff neglect. Research found 105 cases in six countries, including the United States, of elders who died as a result of such violence. All died in long-term care (LTC) homes.3 (See story on resident-to-resident violence in this issue.)

“All 105 incidents were recorded in the context of dementia,” Caspi says. “At least one of the residents involved in the incident had dementia.”

Caspi researched the circumstances surrounding the incidents and found that the majority occurred in residents’ bedrooms, most often in the evening hours or on weekends.

“In the evening and on weekends, there often are lower staffing levels and less meaningful engagement and activities,” Caspi says.

Adequate staffing and activities to keep residents from becoming bored can prevent the resident-to-resident aggression.

“Residents with dementia are more tired in those hours and may be more prone to those episodes when they’re bored and looking for something to do,” Caspi says.

Worse, most were not witnessed by the staff, whose job is to oversee the residents. “Overall, 62% were reported as not witnessed by staff,” Caspi says.

“In a previous study that used videotapes in one home, investigators found that nearly 40% of residents with any physical incidences were not witnessed by staff, and these incidences only took place in public spaces of the long-term care home,” he adds.

So, the question is: How can these facilities increase staffing, especially during the more vulnerable times?

“And how do we make sure staff has adequate training to recognize, prevent, and de-escalate these incidences and involve residents in meaningful activities?” Caspi says.

Another surprising finding was that 44% of incidents were characterized as push-pull, where one resident pushed another resident, causing injury and the resident’s deteriorating condition, he adds.

For example, one person with dementia invades the space of another resident, and that resident may push the first resident away.

“If you push me, I may be able to keep balance, but a 90-year-old person in a walker may fall and have a brain injury and not recover from it,” Caspi says.

Resident-to-resident violence is not premeditated injury within the context of more advanced dementia, he says.

“You may have a resident with mild dementia who does it intentionally, but this is far less common,” Caspi explains. “Some residents have an inclination to be engaging in bullying behaviors, and some were violent in the past with criminal records.”

But the majority of elderly residents who push or attack another resident are not inherently abusive and violent — only frustrated and unable to cope, he says.

Case managers should be aware of this problem when they assist patients with transitions to long-term care facilities. While there is no direct information that compares the number of resident-to-resident incidents between facilities, there are other indicators of problems they can review, Caspi says.

For instance, there’s information on Medicare’s Nursing Home Compare website that rates LTC facilities. It also reports various care-related issues and outcomes as indicators of problems.

A nursing home that has a high number of falls among residents should raise a red flag, Reyes-Ortiz notes.

Case managers should observe all patients and stay alert to signs of neglect or abuse.

“Be sensitive to clinically suspicious signs because abuse generally is underreported, so we need to find the cases proactively,” Reyes-Ortiz says. “See if the patient has a complaint, distress, fear, feelings of helplessness, and physical symptoms, and think about how abuse is underreported.”


1. Daly JM; Butcher HK. Evidence-based practice guideline: elder abuse prevention. J Geron Nurs.2018;44(7):21-30.

2. Reyes-Ortiz CA, Ocampo-Chaparro JM, Campo-Arias AC, et al. Association between history of abuse and falling in older adults. JAGS 2018;epub ahead of print.

3. Caspi E. The circumstances surrounding the death of 105 elders as a result of resident-to-resident incidents in dementia in long-term care homes. JEAN 2018;epub ahead of print.